7 Easy Steps to Prepare for Open Enrollment

Since President Obama signed the Act into law in March 2010, the Patient Protection and Affordable Care Act (also known as the ACA or Obamacare) has made major inroads on its goals of providing accessibility, affordability and quality care for all Americans. Across the board, there have been increases in the number of people that have insurance, slowed growth in insurance costs and systematic changes to the overall approach to patient care: physicians and healthcare systems are now incented to keep people well, rather than only treat them when they are sick.

Improved Quality

Amazing Healthcare Consultants makes it easy to take control of your personal healthcare. Download our FREE Amazing Guide to Open Enrollment Planning Workbook to help you find a balance between affordability and quality healthcare in your insurance coverage. Prioritize your needs, compare plans and avoiding common mistakes.

Download your planning tool today!

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The challenge of Obamacare — as it would have been under any President, Democrat or Republican — is that healthcare is so deeply personal. What looks great in terms of significant statistical improvements brings little comfort in the face of individual pain or family financial struggles. Historically, the insurance industry is, at best, opaque. In virtually every other service industry you would expect to receive an accurate price quote up front, with a detailed breakdown of costs.

Ask yourself… would you take your car in for major repairs, knowing you’re financially responsible for them, and not request a detailed quote up front?

When you get your hair cut and colored, do you expect to receive bills weeks or months later for the scissors, the shampoo, and the hair dye (because other vendors supplied them)?

The thought is ludicrous. And yet, this is the reality of the healthcare system for the past several decades. For better or worse, those lucky enough to have insurance were largely shielded from the full cost of receiving healthcare. No more. The system is in the throes of a long, drawn-out process of improving pricing and service transparency. We’ll get there, but it will not be easy. Or pretty. Amazing Healthcare Consultants believes the system is not perfect, but the best way to feel comfortable with the ACA choices you need to make is to educate yourself on your options. Whether you’re purchasing insurance for the first time from the Federal Marketplace or a state exchange, or renewing your coverage and looking at other options, this Amazing Guide will help you be prepared to make smarter, more informed choices.

OPEN ENROLLMENT DATES FOR 2017

There are several places to buy insurance from, with varying enrollment dates. However, if you buy insurance through the Federal Marketplace or a state healthcare exchange, you have a limited time to buy insurance. Use this chart below to determine when your coverage will begin.

November 1, 2017 to December 15, 2017

If you sign up during this timeframe…

Your coverage will begin:

November 1 - December 15, 2017

January 1, 2018

*Open enrollment dates may vary based on provider Amazing Tip! If you already have insurance, make sure you sign up during the correct period to avoid any gaps in coverage.

Chapter 1:

What is the Affordable Care Act?

Is Obamacare the same thing as the Affordable Care Act? Do we have national healthcare? Do I have to buy insurance? Will it cost me more money? If it seems like there are a lot of questions and confusion about the Affordable Care Act, it’s because the Act isn’t one thing, it’s many. To begin, the Affordable Care Act (ACA) has three goals:

Increase access to healthcare services for all Americans

Make healthcare affordable for all Americans

Improve the quality of care all Americans receive.

A major package of reforms was created to accomplish these goals, which was passed into law by the U.S. Congress. The reforms are known as the Patient Protection and Affordable Care Act, or Obamacare, after President Barack Obama who championed the bill and signed it into law in 2010.

What Does ObamaCare Do?

According to the independent website ObamacareFacts.com, “The Affordable Care Act does lots of important things including:

Offering Americans a number of new benefits, rights, and protections in regards to their healthcare

Setting up a Health Insurance Marketplace (HealthCare.Gov) where Americans can purchase federally regulated and subsidized Health Insurance during open enrollment.

Expanding Medicaid to all adults in many states.

Improving Medicare for seniors and those with long-term disabilities.

Expanding employer coverage to millions of employees.

Requiring most people to have coverage each month from 2014 in order to get an exemption, or pay a fee.

and introducing new taxes and tax breaks, among other provisions.”

It’s important to note that the Federal Government isn’t the supplier of health insurance. And it isn’t a national healthcare system like they have in Canada and Great Britain. Instead, the ACA makes private insurance available to all Americans and regulates the health insurance industry.

Who Offers Health Insurance and How Do You Buy It?

Here’s a handy chart to understand the different ways you can purchase health insurance.

The federal government does not provide health insurance on healthcare.gov. Instead, you purchase private insurance through the Marketplace website, which groups plans from different providers into various categories (Bronze, Silver, Gold and Platinum) to make it easier to compare costs and coverage.

State ExchangesAlso known as State Marketplaces

States can have their own insurance exchanges, or participate in the Federal Marketplace

Private insurance offered through your employer. The employer frequently pays some portion of the monthly premium.

This type of insurance may be for an individual or family. Check to see what your employer covers.
Employer-sponsored insurance may have distinct enrollment periods, and enrollment may be dependent on satisfying certain employment conditions.

Medicaid

Medicaid is a combined federal and state-funded healthcare program for qualifying individuals and families who lack resources to obtain insurance coverage elsewhere.

You must qualify for Medicaid to receive benefits. To apply, or see if you qualify, click here.

Medicare

Medicare is a federally-funded insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD).

Our Guide to Medicare will be published soon

CHIP

CHIP is the Children’s Health Insurance Program, which provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid.

How Much Does Health Insurance Cost?

The most straightforward answer is, it depends. But here are two key things you should know.

Private insurance companies set the cost of health insurance, not the government. To make comparison shopping easier, the ACA requires all private insurance plans in the Marketplace to fall into one of four “metal” categories, Bronze, Silver, Gold and Platinum. These categories cover from 60-90% of your healthcare costs, respectively.

You can earn a tax credit (subsidy) to offset the cost of insurance premiums. Generally speaking, the amount of tax credit received depends on your income. To receive the tax credit, you must purchase health insurance through the Marketplace. Like a discount, the tax credit is applied as you move through the purchase process. The Kaiser Family Foundation noted in their article, Explaining Healthcare Reform: Questions About Health Insurance Subsidies that “the ACA offers subsidies to reduce monthly premiums and out-of-pocket costs in an effort to expand access to affordable health insurance for moderate and low-income people – particularly those without access to affordable coverage through their employer, Medicaid, or Medicare.”

Who Needs Health Insurance Under the Affordable Care Act?

The ACA requires an individual mandate, which means everyone must have some form of qualified health insurance. If you choose not to purchase insurance, you will be fined $695 per adult or 2.5 percent of taxable income when you file your federal income taxes, whichever is higher. Your children will also be fined but at a lower rate.

If you are a lawfully present immigrant, you are eligible to purchase insurance from the Federal or state Marketplaces. If you are illegally in the U.S., you are not eligible for coverage.

How is Healthcare Better with the Affordable Care Act?

Before the ACA, insurance coverage provided by private insurance companies to individuals (or as part of a group employment plan) had unfair limitations and restrictions. The ACA eliminated these restrictions, which ensures expanded coverage for virtually all Americans.

12.7 million Americans Have insurance through the Marketplace 20 million Americans Have insurance through the Marketplace, Medicaid expansion, young adults staying in their parents plan and other coverage provisions.

Pediatric services, including dental and vision care. Amazing Tip! Dental and vision care are essential benefits for children only, not adults.

Amazing Tip! It’s important to note that these benefits do not mean they are free to all Americans, nor are they without limits. You have to know and understand the details of each insurance plan to understand the scope of these benefits.

Coverage for Pre-Existing Conditions

Insurance plans must include treatment for pre-existing conditions. This requirement means any medical condition you have, regardless of whether or not you’ve been diagnosed, must be covered under your healthcare plan. You can’t be rejected, and you can’t be charged more because of your condition. As well, your insurance coverage can’t raise your rates because of your condition either.

Preventive Services for all Adults, Women, and Children

There are three sets of free preventive services. All plans offered through the ACA must include these services without charging a copay or coinsurance. Amazing Tips!

Usually a monthly payment, a premium is the amount of money you must pay to keep your health insurance. You must pay your premium, even if you don’t go to the doctor’s office or take any prescriptions.

Deductible

The amount of money you must pay – through copayments and out-of-pocket expenses – before your insurance starts to pay for services.

Copayment(s)

Also known as copays. The amount of money you pay every time you go to the doctor’s office, urgent care clinic, emergency room or hospital. The amount of the copay will vary based on where you receive services.

Consurance

A type of insurance in which you (the insured) are responsible for paying a share of the cost made against an insurance claim.

Out-of-pocket expenses

The money you must pay (for deductibles, co-pays and coinsurance) for covered services and all costs for any services that aren’t covered. Different healthcare plans offer different levels of out-of-pocket expenses.

Out-of-pocket maximum

This is the most money you have to pay in any given plan year. If you reach this amount, any additional healthcare expenses are covered 100% by your insurance company.

Each of the “metal” plans requires a different mix of premiums, deductibles, copays and out-of-pocket expenses.

A Word About Penalties

If you choose not to buy insurance and don’t have another form of coverage (like through your employer, Medicare or Medicaid), then you will owe a penalty, which is taken from your tax refund. You will owe a penalty for yourself, and everyone in your household not covered by insurance. The penalty is calculated two ways, and you have to pay whichever is higher.

By a Percent of Income

By a Flat Fee

2.5% of household income

Maximum: Total yearly premium for the national average price of a Bronze plan sold through the Marketplace

$695/adult

$347.50/child under 18

Maximum: $2,085

Beginning in 2017, the flat fee will adjust for inflation.

What If My Eligibility Changes in the Middle of a Plan Year?

If you get married, divorced, have a baby (including adoption), or lose existing health insurance coverage on your own or through a family member, you are eligible for a Special Enrollment Period. It’s easy to figure out if you qualify. Go to https://www.healthcare.gov/screener/ to be guided through a series of questions. Learn more about other circumstances that might qualify you for a Special Enrollment Period on healthcare.gov. https://www.healthcare.gov/screener/marketplace.html AMAZING TIP! If you haven’t been to the healthcare.gov website, or only heard horror stories about it from the beginning, take a fresh look. It’s friendly and easy to navigate. You can also apply for CHIP (Children’s Health Insurance Program) and Medicaid at any time.

Chapter 4:

7 Easy Steps to Prepare for Open Enrollment

Step 1: Document Your Medical Needs

Before you start looking at options, it’s a good idea to document your medical needs for the past year or two, to get an understanding of what kind of health coverage you’ll need.

List all Known Medical Conditions

List All Medications

# Doctor’s Visits in the Past 12 Months

# Emergency Room Visits in the Past 12 Months

Me

My Spouse

Child #1

Child #2

Step 2: Look at Your Current Healthcare Costs

It’s also a good idea to look at your total healthcare costs. If you’re super-organized, or use a personal finance tool like Quicken or Mint, you may easily be able to total your costs over the past year. If not, then use the chart below to create a baseline for you and your family. Remember to look at all your Explanation of Benefits documents (EOBs). These documents from your current insurance plan list which service(s) you or a family member received, how much each service cost, and how much you and the insurance company would pay. Add them up and fill out the chart below.

Example

Current Plan

Monthly premium x 12

$300/month x 12 months

Annual Deductible

$1,000

Copay - primary care

$20 x 5 visits

Copay - specialist

$40 x 2 visits

Copay Urgent/ER care

$120 x 0 visits

Prescription drug copay*

($2/month x 12 months)
+
($40/month x 12 months)

Co-insurance

$XXXX

Other**

$325

Total costs

$XXXX

*Prescription drug copays will vary depending on the prescribed medication, whether it’s generic or brand-name, et cetera. Pricing has been simplified for this example. **Other medical costs might include covered medical supplies or equipment Amazing Tip! It’s important to remember that some medical expenses are not covered, or covered for a limited amount. For example, elective surgery may not be covered and chiropractic care and physical therapy may be covered but only for a limited number of visits. Amazing Tip! Take the time to do your research! Once you purchase a plan, you cannot change it unless you qualify for a Special Enrollment Period.

Step 3: Determine Which Metal Plan Is Right for You

Good news: All healthcare plans must provide the ten essential healthcare benefits. To make comparison shopping easier, all Marketplace plans are grouped into one of four “metal” categories: bronze, silver, gold and platinum. Bad news: You have to read the fine print of each policy to understand the differences between two plans at the same “metal” level.

Amazing Tip! Typically, Bronze plans have the lowest monthly premiums but require the highest out-of-pocket expenses. Platinum plans, on the other hand, have high monthly premiums but lower out-of-pocket expenses. Use the worksheet in Step 2 to compare the total cost of insurance (premiums, copays and co-insurance) when you evaluate different plans The Metal Plan that’s Best for Me and My Family Is: ___________________________. (Choose 1: Bronze, Silver, Gold, Platinum)

Amazing Healthcare Consultants makes it easy to take control of your personal healthcare. Download our FREE Amazing Guide to Open Enrollment Planning Workbook to help you find a balance between affordability and quality healthcare in your insurance coverage. Prioritize your needs, compare plans and avoiding common mistakes.

Download your planning tool today!

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Step 4: Determine Which Insurance Type is Right for You

In addition to determining what percentage of healthcare costs you’re willing to pay, you’ll need to determine the best type of insurance for you and your family. Each plan has pros and cons: consider your options based on your individual and family needs.

Tax credits, or subsidies, are available for qualifying Americans. With a tax credit, you’ll have a lower monthly premium for your health insurance. Your income determines your eligibility, so you’ll need to check in the Federal or state Marketplace to know for sure. Check online to see if you’re eligible for premium tax credits. How can you save money with a tax credit? It can be a bit complicated.

Step 6: Research Specific Insurance Plans

Once you’re confident you understand the types of plans that are available, it’s time to start thinking about your personal situation: are you buying insurance for yourself or your family? Are you relatively healthy? Do you have current medical conditions that require ongoing treatment? What prescription drugs, if any, do you (or people in your family) take? Use your worksheet from Step 1, and your answers from Steps 2, 3 and 4 and let’s go online. You might also want to review the information listed in this handy Marketplace checklist. The healthcare.gov Marketplace (or equivalent state exchanges) will guide you step-by-step through the process. Here’s what you would have seen in 2016: Amazing Tip! New for the 2017 enrollment year, you’ll be able to add your preferred doctors, medical facilities and prescription drugs so you’ll know right away if your preferences are covered by the plans you’re evaluating. Check out 2017 enrollment dates here! Start researching plans as soon as they are available in the Marketplace.

Step 7: Sign Up, Re-Enroll or Change Insurance

Open Enrollment 101

Open enrollment is an opportunity to enroll, update or change insurance plans. Although you may have heard horror stories about long waits or unresponsive websites, the Marketplace continues to improve every year. Amazing Tip! Don’t wait until the last minute to sign up. You’ll enjoy shorter wait times and less harried customer service agents.

Open Enrollment Dates

November 1, 2016 – January 31, 2017

If you sign up during this timeframe…

Your coverage will begin:

November 1 - December 15, 2016

January 1, 2017

December 16, 2016 - January 15, 2017

February 1, 2017

January 16 - January 31, 2017

March 1, 2017

Sign Up for Insurance

You can sign up online, in person, using a paper form or over the phone.

Re-enroll in Your Current Insurance Plan

If you don’t proactively change plans, you will be automatically enrolled in the same plan as the current year. Unless you qualify for a Special Enrollment Period, you will not be able to make changes after open enrollment ends. Amazing Tip! Even if you’re satisfied with your current healthcare plan, look carefully at the details. Specifics about premiums, deductibles, copays and who’s in (or out) of network frequently change from year to year. Trying to cancel or disenroll in a policy you inadvertently re-enrolled in can be laborious and time-consuming. Be sure to know your coverage dates, and make changes before automatic re-enrollment happens.

Change to a Different Health Insurance Plans

During Open Enrollment, you are free to change to another health insurance plan. Check the dates carefully. Be sure that you have full coverage, and that your plans do not overlap or create gaps in your insurance status.

Congratulations!

You’re now one of the 90% of Americans with health insurance. But don’t stop there. Be sure to eat healthy, exercise regularly and take care of yourself. [callout1]Still struggling to find the best insurance plan for you and your family? Amazing Healthcare Consultants can help you evaluate plans to maximize your benefits and shield you from hidden costs. Connect with us at info@amazinghcc.com or 888-568-0011.[/callout1]

Chapter 5:

AMAZING HEALTH INSURANCE GLOSSARY

Do you know your health insurance vocabulary? Check out our glossary before you go shopping for health plans online.

Types of Insurance Payments

Term

Definition

Premium

Usually a monthly payment, a premium is the amount of money you must pay to keep your health insurance. You must pay your premium, even if you don’t go to the doctor’s office or take any prescriptions.

Deductible

The amount of money you must pay – through copayments and out-of-pocket expenses – before your insurance starts to pay for services.

Copayment(s)

Also known as copays. The amount of money you pay every time you go to the doctor’s office, urgent care clinic, emergency room or hospital. The amount of the copay will vary based on where you receive services.

Consurance

A type of insurance in which you (the insured) are responsible for paying a share of the cost made against an insurance claim.

Out-of-pocket expenses

The money you must pay (for deductibles, co-pays and coinsurance) for covered services and all costs for any services that aren’t covered. Different healthcare plans offer different levels of out-of-pocket expenses.

Out-of-pocket maximum

This is the most money you have to pay in any given plan year. If you reach this amount, any additional healthcare expenses are covered 100% by your insurance company.

Point of Service
A health plan where you pay less if you see a doctor in the provider’s or underwriter’s network.

Yes, in a limited manner

No

Flexible options, so long as you see a specialist that your primary care doctor refers

About Amazing Healthcare Consultants

Founded in 2011 by Dr. Carol DeVore, Amazing Healthcare Consultants provides clear sightlines into your loved one’s healthcare through personal patient advocacy and insurance advocacy. Making confident and educated healthcare decisions is the ultimate peace of mind, and as an independent agency, Amazing Healthcare Consultants puts the patient first and fights for the best care and coverage possible. To learn more about Amazing Healthcare Consultants or to schedule a free consultation, request a call from us.